Preventive
| Service | Description | Recommendations/Limitations |
|---|---|---|
| Blood Pressure Measurement | Measurement of blood pressure. | Recommended at each office visit or every two years up to age 65; annually above 65. |
| Weight/Height Measurement | Measurement of weight and height. | Recommended at each visit. For members under age 21 years BMI measurements should begin at age 2 years and be done at each visit according to EPSDT guidelines. |
| Total Cholesterol Measurement | Measurement of total cholesterol level. | Recommended every five years from ages 35-65 for men and every five years from ages 45-65 for women. |
| Breast Cancer Screening | Mammography alone or mammography and clinical breast exam. | Recommended once a year for women beginning at age 40 or as recommended by the physician. |
| Cervical Cancer Screening | Pap test and pelvic exam. | Recommended once every calendar year for women ages 18-65. |
| Chlamydia Screening | Screening for chlamydia infection | All sexually active women and other asymptomatic women at increased risk for infection. |
| Colorectal Cancer Screening | Single sigmoidoscopy or annual fecal occult blood test. | Recommended: Fecal occult blood test or stool blood test annually and/or sigmoidoscopy every five years at age 45 and above. |
| Prostate Cancer Screening | Digital rectal exam and prostate specific antigen. | Limitation: For men age 50 or older or as recommended by the physician. |
| Tuberculin Skin Testing | Testing for exposure to tuberculosis; includes reading of test results. | For members under age 21 years, recommended based on TB high risk assessment. For members age 21 and older, as needed. Limitation: One test per benefit year for adults age 21 and older. |
| Health Education and Counseling | Covers various topics including risks of smoking and alcohol/drug use, nutrition and exercise, lap/shoulder car seat belt use, safety and injury prevention, and high-risk sexual behavior. Also for women: adequate calcium intake and unintended pregnancy. | Recommended during a physical exam. |
| Immunizations | Flu vaccine. Tetanus-diphtheria (Td) booster. Pneumococcal vaccine. Rubella (or evidence of immunity) for women of child-bearing age. Hepatitis A. Hepatitis B in high-risk groups. Other immunizations recommended by the physician. | Limitation: Does not include immunizations needed for travel. Vaccines for members age 18 years and under must be obtained from the Department of Health’s Vaccines for Children program. May use private stock for members age 19 years and older. |
| Chemoprophylaxis – Adults | Multivitamin with folic acid for pregnant women and women actively trying to become pregnant. For peri- and post-menopausal women: counseling about the potential benefits and risks of hormone prophylaxis and related treatment. | |
| Nutrition counseling by licensed dietitian | Diabetes self-management training (DSMT) Nutrition counseling for obesity When medically necessary for other metabolic conditions | Requires a physician’s order and must be part of a treatment program to mitigate the effects of an illness or condition. |
Inpatient Hospital Services (including behavioral health)
| Service | Description | Recommendations/Limitations |
|---|---|---|
Inpatient Stay – Adults, including:
| All medically necessary services to diagnose and treat acute and/or serious medical conditions in a hospital under the direction of a licensed physician. The attending physician will determine how long a patient must stay in the hospital. Stays after vaginal delivery can be up to 48 hours, or 96 hours after Caesarean section delivery, for healthy women with uncomplicated deliveries and postpartum stays. Also includes all medically necessary non-experimental diagnostic and/or therapeutic services allowed under federal Medicaid rules and regulations. | Limitation: Precertification is required for prior-day admissions for elective procedures. (It is expected that the patient will be admitted on the day the procedure is scheduled.) Precertification is required for an inpatient stay for services normally done on an outpatient basis in an ambulatory surgicenter or doctor’s office. Properly executed patient consent forms are required for sterilizations (Form 1146) and hysterectomies (Form 1145). |
Outpatient Hospital Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
Outpatient Hospital – Adults, including:
| Services may be preventive, diagnostic, therapeutic, rehabilitative, or palliative. Also includes all medically necessary non-experimental diagnostic and/or therapeutic services allowed under federal Medicaid rules and regulations. | Limitation: Precertification is required if procedures normally done in the doctor’s office will be done in an ambulatory surgery center. Precertification is required for physical therapy and for occupational therapy that exceed the established guidelines for the condition under treatment. Precertification is required for speech therapy. |
Emergency Room and Urgent Care Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
| Emergency Room Services | Services provided in an emergency room for emergent or urgent services. | Limitation: Members may have to pay either a copayment or the full cost of a non-emergent visit. |
Other Facility Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
| Skilled Nursing Facility | Services provided at a skilled nursing level of care whether in an acute care hospital or skilled nursing hospital. Services must be medically necessary. For individuals younger than 21: Also includes all medically necessary skilled nursing services allowed under federal Medicaid rules and regulations. | |
Hospice, including:
| Medically necessary services to patients with a life expectancy of six months or fewer provided in the home, outpatient, and inpatient settings by agencies certified by Medicare as hospice agencies. For individuals younger than 21: Also includes all medically necessary hospice care allowed under federal Medicaid rules and regulations. | Limitation: While under hospice care, members receive all services related to the terminal condition from the hospice. Children under age 21 years can receive treatment to manage or cure their disease while concurrently receiving hospice services. For adults, only services unrelated to the terminal condition can be obtained from other providers. |
Physician Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
Physician Services, including:
| Services provided within the scope of practice of allopathic or osteopathic medicine. Services must be medically necessary and non-experimental. For individuals younger than 21: Also includes all medically necessary non-experimental diagnostic and/or therapeutic services allowed under federal Medicaid rules and regulations. | Limitation: Members must get a referral from their PCP before going to see a specialist. Specialty services without a referral from the PCP are not covered. QUEST Integration covers only one visit a day to a physician. If a physician refers a patient to another doctor on the same day, the visit to the specialist is also covered. |
Pregnancy and Maternity Care
| Service | Description | Recommendations/Limitations |
|---|---|---|
Pregnancy and Maternity Care, including:
| Prenatal visits as currently recommended by the American College of Obstetrics and Gynecology. Health education and screening for fetal development, breast-feeding, labor and delivery, and conditions that could make a pregnancy difficult. Diagnosis of premature labor. Diagnostic amniocentesis, diagnostic ultrasound, and fetal stress and non-stress testing. For individuals younger than 21: Also includes all medically necessary non-experimental diagnostic and/or therapeutic services allowed under federal Medicaid rules and regulations. | Lactation counseling and breast pump rental is covered for up to six months but may be extended for premature infants or as needed. |
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
EPSDT Services, including:
| For individuals younger than 21: Includes all services covered under QUEST Integration | Limitation: Some services require a referral or a precertification. There are no limits for medically necessary, non-experimental services. Immunizations should be provided according to current recommendations of the Hawaii State Dept. of Health, Advisory Committee on Immunizations. |
Family Planning Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
Family Planning Services, including:
| Services provided to males and females who are sexually active and of child-bearing age. Services must be voluntary and confidential. For individuals younger than 21: Also includes all medically necessary family planning services allowed under federal Medicaid rules and regulations. | Limitation: Sterilizations require written informed patient consent at least 30 days before the procedure is rendered. Sterilizations are not covered for a patient younger than 21, those judged mentally incompetent, or those who are institutionalized. Reinsertion of implantable contraceptives requires approval if done within five years of a previous insertion. Over-the-counter supplies must be prescribed by a physician or other health care provider licensed to prescribe. |
Standard Behavioral Health Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
Inpatient hospitalization Ambulatory mental health services, including crisis management Psychotropic medications and medication management Psychiatric or psychological evaluation and treatment
Medically necessary alcohol and chemical dependency svcs Methadone management services for acute opiate detoxification and maintenance Additional comprehensive and specialized benefits for adults with SMI or SPMI are available within the CCS program, including inpatient, outpatient therapy and tests to monitor response to therapy, and intensive case management. Alcohol and/or drug abuse treatment is also available. Additional benefits for children/youth less than 21 years of age with SEBD are available through the DOH Children and Adolescent Mental Health Division (CAMHD) Support for Emotional and Behavioral Development (SEBD) program. | Services provided by a licensed psychiatrist, psychologist, advanced practice registered nurse or licensed social worker. For individuals younger than 21: Also includes all medically necessary behavioral health services allowed under federal Medicaid rules and regulations. | Limitation: Precertification through HMSA's behavioral health services is required for out-of-state services and methadone/LAAM treatment. |
Prescription Drugs
| Service | Description | Recommendations/Limitations |
|---|---|---|
| Prescription Drugs (refer to QUEST Integration Drug Formulary) determined medically necessary to optimize a medical condition, including behavioral health prescription drugs for children receiving services from CAMHD. | Drugs, including certain over-the-counter drugs prescribed by a physician or other health care provider licensed to prescribe drugs. Medications required to be covered by statue, including antipsychotic medications and continuation of antidepressants and anti-anxiety medications prescribed by a licensed physician for FDA approved treatment of a mental or emotional disorder are covered without limit. Medications to treat non-pulmonary and latent tuberculosis not covered by the Dept of Health are covered by QUEST Integration. For individuals younger than 21: Also includes all medically necessary prescription drugs allowed under federal Medicaid rules and regulations. | Limitation: Most kinds of drugs are covered when generics are used. If a specific brand name drug is needed instead of the generic, or if the drug needed is not on the QUEST Integration Formulary, precertification of the drug is required. An emergency supply of medication for at least seven (7) days can be provided to the member during the precertification process for new drugs. Precertification is not required for medications approved by the FDA to treat members suffering from human immunodeficiency virus, acquired immune deficiency syndrome, or hepatitis C, or a member in need of transplant immunosuppressives. |
Cognitive Rehabilitation Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
| Services provided to cognitively impaired persons (e.g. traumatic brain injury). | Assess and treat communication skills, cognitive and behavioral ability and cognitive skills related to ADL Approaches and techniques include education, process training, strategy development and implementation, functional applications. | Treatment may last up to one year if the patient is making progress. |
Habilitation Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
| Services must be medically necessary. | Services do not include coverage of routine vision services. |
Rehabilitation Services (Inpatient and Outpatient)
| Service | Description | Recommendations/Limitations |
|---|---|---|
| Rehabilitative or facilitative therapy to prevent regression or to prevent or delay institutionalization. For individuals younger than 21 years:Also includes all medically necessary services and related medical supplies and equipment allowed under federal Medicaid rules and regulations. | Limitation:Limited to patients who are expected to improve in a reasonable period of time. Rehabilitation services, except for the initial evaluation, require precertification, subject to variable intensity review. |
Other Services
| Service | Description | Recommendations/Limitations |
|---|---|---|
Smoking cessation
| Services available state-wide. | Limitation: 2 quit attempts per benefit year |
| Prostheses and Orthoses | Prostheses and orthoses to restore function or replace the function of a body part For individuals younger than 21: Also includes all medically necessary prostheses and orthoses allowed under federal Medicaid rules and regulations. | Limitation: Precertification is required for items costing more than $500. Penile and testicular prostheses and related services are not covered. |
| Durable Medical Equipment and Implants | Medically necessary medical equipment, either purchased or rented, to reduce medical disability and restore or improve the patient’s functional level. For individuals younger than 21: Also includes all medically necessary durable medical equipment allowed under federal Medicaid rules and regulations. | Limitation: Precertification from HMSA is required for purchase or rental of equipment costing more than $500. |
| Medical Supplies | Medically necessary medical supplies allowed under federal Medicaid rules and regulations. | Limitation: Precertification is required for supplies used with durable medical equipment if the monthly cost is more than $500. Personal care items and non-medical items are not covered. |
Vision Services, routine eye examinations, routine and medically necessary vision appliances (including prescription lenses, contact lenses, prosthetic eyes, ophthalmologic exam with refraction, or to improve vision due to a medical reason, etc.) Medical eye examination | Refer to the “Recommendations/Limitations” section for more information on your vision services. Medical eye examination: Visits to the eye doctor for an eye condition (i.e., medical condition) or for a change in visual acuity (i.e., clarity of vision) will be covered under your medical plan (i.e., HMSA QUEST Integration, not EyeMed). | Effective January 1, 2022, HMSA has partnered with EyeMed to administer your vision benefits. For HMSA QUEST Integration, EyeMed is responsible for the following.
For more information, please visit EyeMed at www.eyemedinfocus.com. Eye surgery to improve vision so a patient no longer needs glasses is not covered (i.e., Refractive Eye Surgery). |
Hearing Services, including:
| Medically necessary hearing aids, with standard features. Includes service/loss/damage warranty, and trial or rental period. | Limitation: Only one hearing aid evaluation is covered over a 12-month period. Hearing aid fitting/orientation/check – 2 times in 3 years for under age 21 years, once in 3 years for over age 21 years. Hearing aids covered once in a 24 month period. |
| Ambulance Services | Ground and air ambulance services for medically necessary transportation. | Limitation: Only for transportation to or from an acute care facility. |
Transportation Services, including:
| Ground transportation services for members with no transportation to medical appointments and who reside in areas not serviced by public transportation or who cannot access public transportation. Air transportation including lodging and meals for the member and (if needed) an attendant required for the member to obtain medically necessary diagnosis and treatment services that are not available on the member’s home island. For individuals under age 21: Also includes all medically necessary transportation services allowed under federal Medicaid rules and regulations. | Limitation: Precertification for transportation is required. Individuals under age 18 and those with special travel needs are allowed one attendant. The attendant must be age 18 or older and able to help during travel. |
Home Health Services, including:
| Services provided at a member’s home by qualified home health agencies when a member is homebound because of an illness or injury and requires part-time or intermittent care. Services can also be provided at a location other than a hospital, skilled nursing facility, intermediate care facility, or intermediate care facility for mental retardation. For individuals younger than 21: Also includes all medically necessary home health services allowed under federal Medicaid rules and regulations. | Limitation: Precertification is required every 30 days. |
Other Practitioner Services, including those by:
| Services that are medically necessary and non-experimental that are within the scope of practice that the practitioner is legally authorized to perform under state law. For individuals younger than 21: Also includes medically necessary chiropractic services allowed by federal Medicaid rules and regulations. | Limitation: Some services may require a referral from the PCP. |
| Dialysis Services, including equipment, supplies, diagnostic testing, and drugs | Hospital inpatient, hospital outpatient, non-hospital renal dialysis facility or patient’s home. Laboratory tests including Hepatitis B surface antigen (HBsAg) and Anti-HB testing for patients on Hemodialysis, Intermittent Peritoneal Dialysis (IPD), and Continuous Cycling Peritoneal Dialysis (CCPD). Hepatitis B vaccines. Alfa Epoetin (EPO) when provided during dialysis. Other drugs related to ESRD. Home dialysis equipment prescribed by a physician. Continuous ambulatory peritoneal dialysis (CAPD), a variation of peritoneal dialysis, that is an alternative mode for dialysis for home dialysis patients. Physician’s services. Inpatient hospitalization when the hospitalization is for an acute medical condition requiring dialysis treatments, a patient receiving chronic outpatient dialysis is hospitalized for an unrelated medical condition or for placement, replacement or repair of the chronic dialysis route. | Services must be provided by participating Medicare certified facilities, and Medicare certified End Stage Renal Disease providers. |
Podiatry services
| Treatment of conditions of the foot and ankle, including diabetic foot care. | Routine foot care (cutting/removing corns or calluses, trimming nails, hygienic or preventive services) is not covered. |
| Sleep Laboratory Services | Diagnosis and treatment of sleep disorders. | Providers must be accredited by the American Sleep Disorders Association. |
Diagnostic tests including but not limited to:
| Precertification requirements may apply to specific tests. | |
| Surgeries performed in free-standing ambulatory surgery center (ASC) and hospital-based ASC | Precertification is required for services normally done in the physician office. | |
| Medical services related to dental needs |
Long-term Services and Supports (LTSS)
Services may be provided to persons approved to receive these services through the DHS Form 1147.
Some services can also be provided for individuals who are at risk of deteriorating to the institutional level of care and who meet “at risk” criteria using the assessment tool provided by DHS. These “at risk” services are identified by an asterisk (*). See also, Services for “At Risk” Members below.
| Service | Description | Recommendations/Limitations |
|---|---|---|
Institutional Services include:
| A patient assessment for level of care is necessary on the DHS Form 1147 only when Medicaid is the primary payer for the service. If a member has other insurance that is primary to QUEST covering the services, we will follow the appropriate coordination of benefits rules, and an approved 1147 form would not be required. | |
Home and Community-based services include the following:
| Supportive care to 4 or more disabled adults Observation and supervision Coordination of behavioral, medical and social plans Implementation of the service plan | Limitation: Adult day care staff may not perform healthcare related services (e.g., medication administration, tube feeding, etc.). Precertification is required. |
Adult day health for adults with physical or mental impairments, or both (*)
| Limitation: Nursing services must be under the supervision of a registered nurse. Precertification is required. | |
Assisted living facility (ALF) services
| Limitation: Payment for room and board is not covered. | |
| Community Care Management Agency (CCMA) services to persons living in Community Care Foster Family Homes (CCFFH), Expanded Adult Residential Care Homes (E-ARCHs), ALFs and other community settings. | CCMAs must provide ongoing services to members living in CFFH, E-ARCHs, ALFs and other community settings as required. | |
Community Care Foster Family Home (CCFFH) services
| Services provided in a private home by principal care provider who lives in the home. Number of adults receiving services can be up to 3 persons, each with their own bedroom unless they consent to share a room. | Limitation: Precertification is required. |
| Counseling and training provided to members, families/caregivers, and professional and paraprofessional caregivers on behalf of the member | Nature of the disease; methods of transmission and infection control measures; biological, psychological care and special treatment needs/regimens; employer training for consumer directed services; instruction about the treatment regimens; use of equipment; employer skills updates as necessary to maintain the individual at home; crisis intervention; supportive counseling; family therapy; suicide risk assessments and intervention; death and dying counseling; anticipatory grief counseling; substance abuse counseling; and/or nutritional assessment and counseling on coping skills to deal with the stress of a deteriorating functional, medical, or mental status | Qualified health care professionals to provide counseling and training include:
Note: Respiratory therapists must have passed the state-administered national examination and be either certified (CRT) or registered (RRT). |
Environmental accessibility adaptations that give the member greater independence in the home
| Services must be necessary to ensure the health, welfare and safety of the individual. | Limitation: Prior authorization is required. Window air conditioning units may be installed when necessary for the health and safety of the member. Excluded are adaptations that are of general utility and not direct medical or remedial benefit to the member (e.g., carpeting, roof repair, central A/C, etc.). Adaptations that add to the total square footage of the home are excluded. All adaptations must meet state or local building codes. |
| Home delivered meals (*) | Limitation: Meals do not replace or substitute for a full day's nutritional regimen. Excludes residential or institutional settings. | |
| Home maintenance services | Services to bring a home up to acceptable standards of cleanliness at the start of a service plan if needed. Services that maintain a safe, clean and sanitary environment, i.e. minor repairs to essential appliances, fumigation/extermination services, etc. | |
| Moving assistance in the rare instances when a person needs to relocate from a home that is unsafe, inaccessible, or unable to support needed equipment; or due to eviction or other economic reasons. | Limitation: Prior authorization is required. | |
| Non-medical transportation to access community services, activities and resources specified in the service plan | Limitation: Not covered for members living in residential care settings or a CCFFH. | |
Personal assistance services – Level I and Level II – provided in the member’s home to help with IADLs and ADLs. (*)
| Level I
Level II
| Limitation: Services must be approved by the service coordinator in the service plan. |
| Personal emergency response system (PERS) (*) | 24-hour emergency assistance service for emotional, physical, or environmental emergencies. | Limitation: Limited to persons who live alone or who are alone for a significant part of the day and who live in an unlicensed setting. |
| Residential care services provided in a licensed private home | Furnished in a Type I Expanded Adult Residential Care Home (EARCH) or in a Type II EARCH. Members receiving residential care services must be receiving ongoing CCMA services. | |
| Respite care on a short-term basis for persons unable to care for themselves and whose caregiver is absent or in need of relief | May be hourly, daily and overnight. May be provided in the home or place of residence, CCFFH, E-ARCH, nursing facility, licensed respite day care facility, or other community care residential facility. | Must be authorized by the PCP as part of the service plan. |
| Skilled (or private duty) nursing for persons needing ongoing nursing care (*) | Must be provided by licensed nurses and be within the scope of state law and authorized in the member's service plan. | |
| Specialized medical equipment and supplies | Devices, controls, or appliances specified in the service plan to enable persons to increase and/or maintain their abilities to perform ADLs or live in their environment. Also includes items necessary for life support, ancillary supplies and equipment necessary to the proper function of such items, and durable and no-durable medical equipment not available under Medicaid.
| Excludes items that are not of direct medical or remedial benefit to the member. Must be recommended by the PCP and approved as part of the service plan. Must meet standards of manufacture, design and installation. |
Services for “At Risk” Members
| Service | Description | Recommendations/Limitations |
|---|---|---|
| Supportive care to 4 or more disabled adults Observation and supervision Coordination of behavioral, medical and social plans Implementation of the service plan | Limitation: Adult day care staff may not perform healthcare related services (e.g., medication administration, tube feeding, etc). Precertification is required. |
Adult day health for adults with physical or mental impairments, or both:
| Limitation: Nursing services must be under the supervision of a registered nurse Precertification is required. | |
| Home delivered meals | Limitation: Meals do not replace or substitute for a full day’s nutritional regimen. Excludes residential or institutional settings. | |
| Personal assistance services – Level I and Level II – provided in the member’s home to help with IADLs and ADLs. | Level I:
Level II
| Limitation: Services must be approved by the service coordinator in the service plan. |
| Personal emergency response system (PERS) | 24-hour emergency assistance service for emotional, physical, or environmental emergencies | Limitation: Limited to persons who live alone or who are alone for a significant part of the day and who live in an unlicensed setting |
| Skilled (or private duty) nursing for persons needing ongoing nursing care | Must be provided by licensed nurses and be within the scope of State law and authorized in the member’s service plan. |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|